Nurse Lisa Meadows works on a mobile medical van that visits the area's elementary schools where as many as 25 percent of the students have asthma.

"Many children are walking around very sick," but they don't know they don't have to be, Meadows said. "It's not unusual for me to see severe obstruction in children who think it's normal for them to have to stop running and playing in gym class."
Nationwide, about 1 in 10 children has asthma. But in some of the poorest areas in north St. Louis and St. Louis County, a staggering 1 in 5 has the chronic disease, recent studies have found.
Asthma is a lung disease that causes episodes of breathing difficulty. But most people can live symptom-free if they receive medical care, use medications properly and limit triggers in their environment.
Yet four children under age 15 died from asthma in the city and county in 2009 and 2010, the latest numbers available.
"We lose about two kids a year because of asthma," said Jeanine Arrighi, a children's environmental health services manager with the city's health department.
Asthma has become the leading chronic condition among children, with poor, inner-city minorities bearing the brunt.
Black children vulnerable
In St. Louis and St. Louis County, black children are 7.5 times more likely than white children to visit the emergency room for asthma, a figure that has persisted over the past decade, according to this month's release of the St. Louis Regional Health Commission's study on the area's health. Black children are also 6.6 times as likely to be hospitalized for asthma.
At the same time, strides were made in the past 10 years in the rates of heart disease, stroke, diabetes, cancer and infant mortality. Childhood lead poisoning has fallen by more than 80 percent.
"There have been so many positive changes in so many other health conditions, but childhood asthma still remains a huge challenge," Arrighi said.
The discouraging numbers spurred advocates with the local chapter of the Asthma and Allergy Foundation of America to travel to Jefferson City this month to push for more services to be covered under Medicaid, the publicly funded health insurance for the poor. They are asking for a case management approach to asthma that includes access to a primary care doctor, help with medication and home assessments.
"We're missing the boat," said Joy Krieger, the St. Louis chapter's director. "There are a lot of kids who need this, but the financial incentives aren't there."
Children often end up in the emergency room, where they leave with a confusing list of prescriptions and orders to follow up with a primary care doctor, Krieger said. Many can't pay for all the medications, lack transportation and are given a doctor's appointment several weeks out.
The different devices and equipment used to take the medications are confusing and often are used incorrectly. Many people buy the cheaper "rescue" medicine for emergencies and forgo medications used to help manage the disease. Some patients may think they are better and stop using medicine altogether. The result is a trip back to the emergency room.
It can be difficult for patients even with insurance.
A study by the Midwest Health Initiative released three years ago followed patients with Medicaid and private insurance. Researchers found that in the city, 90 percent of patients treated in the emergency room for asthma did not follow up with a primary care doctor within 10 weeks. Nearly 80 percent did not fill their prescriptions. In the county, 76 percent did not follow up with a doctor and about the same never got their medicine.
Karen Tobias, 46, of Pagedale, says she works hard to make sure her daughter, 9, makes it to her doctor appointments and takes all her medications. Tobias feels that she is doing everything she can, yet her daughter still has been to the emergency room three times this winter.
"Every time the weather changes, she gets sick," Tobias said. "I miss work, and she misses school." Her daughter's pediatrician and pulmonologist need to change her medications, and she needs to add an allergist to the list of doctors she sees.
Healthy Kids Express
Krieger argues that a case management approach would save money and lives, and similar efforts such as the St. Louis Children's Hospital's outreach into hard-hit schools with their mobile medical van have shown results.
The Healthy Kids Express van began visiting schools in 2009 in the Normandy School District and parts of the city -- focusing on schools with high rates of poverty and hospitalization for asthma. The van's health care team sees about 600 children a year, often more than once a month, and tests how well the children are controlling their asthma and taking their medications. The health care team works closely with parents and pediatricians in developing care plans. The program also involves training teachers and school nurses.
Children visited by the van are missing fewer days of school and reducing their hospital trips by 25 percent. They show better technique with their inhalers and know more about their disease.
"Parents want to do the right thing for their children, but the system is so fragmented, and it's so complex," Meadows said. "If they can be guided and recognize what is most important and work on those goals first, we can make a dent."
At Christian Hospital in north St. Louis County, nurse and asthma educator Alishia LaPorte began a program this year that targets uninsured patients treated for asthma in the emergency rooms at the hospital's main campus on Dunn Road as well as its facility in Florissant.
Each day, LaPorte gets a list of those patients. She calls or writes each one. If they can't pay for prescriptions, she helps them apply for financial assistance programs offered by many drug companies. LaPorte connects them to primary physicians at the hospital, which sees it as cost-savings measure to provide the doctor visits at little or no cost. She's also available by phone to answer questions.
"I am able to save a lot of patients from coming into the ER by walking them through their asthma action plan," LaPorte said. "We look to see if we can turn things around at home."
Wanting to replicate the success that efforts to reduce lead poisoning have achieved, the city health department won a $533,000 grant from the Missouri Foundation for Health to target asthma. The money helped increase from two to 20 the number of staff who have a role in asthma education and reduction and start a home assessment program that involves checking for asthma triggers inside homes. A similar program is about to begin in St. Louis County with funding from the Environmental Protection Agency.
The home assessments can be a powerful tool, according to results in southeastern Missouri, where county health departments teamed up with Southeast Missouri State University seven years ago. About 100 homes are checked for triggers each year, said John Kraemer, a biology professor who studies indoor air quality and health at the university. Those who participate have 80 percent fewer emergency room visits than those who don't.
"We have a lot of data to show that it is helpful to patients," Kraemer said.
In St. Louis city -- where health department efforts also have included adding educational programs in private and parochial schools and assessing day cares for asthma triggers -- hospitalizations of children for asthma have dropped 6 percent among the Medicaid population over the past 10 years.
Arrighi at the city health department said advocates, health care providers and researchers were still working to identify the reasons behind the still-dismal statistics and racial disparities.
The next meeting is Jan. 15, she said, when participants will discuss what can be done to put the focus on prevention.
"We are dealing with treating asthma exacerbations instead of finding ways to prevent asthma complications," Arrighi said. "There's a lot of momentum right now in the community to make changes that will result in better health outcomes for asthma."
(c)2012 the St. Louis Post-Dispatch
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